Choice of revascularization strategy for ischemic cardiomyopathy due to multivessel coronary disease

Anas H Alzahrani; Shinobu Itagaki; Natalia N Egorova; Joanna Chikwe

doi:10.1016/j.jtcvs.2024.03.007

Choice of revascularization strategy for ischemic cardiomyopathy due to multivessel coronary disease

J Thorac Cardiovasc Surg. 2024 Mar 15:S0022-5223(24)00208-3. doi: 10.1016/j.jtcvs.2024.03.007. Online ahead of print.

Authors

Anas H Alzahrani¹, Shinobu Itagaki², Natalia N Egorova³, Joanna Chikwe⁴

Affiliations

¹ Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
² Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
³ Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: natalia.egorova@mountsinai.org.
⁴ Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.

PMID: 38492720
DOI: 10.1016/j.jtcvs.2024.03.007

Abstract

Objective: Limited comparative data guide the decision between coronary artery bypass grafting and percutaneous coronary intervention for multivessel revascularization in ischemic cardiomyopathy. The study objective was to compare the long-term outcomes of coronary artery bypass grafting and percutaneous coronary intervention for ischemic cardiomyopathy.

Methods: Clinical registries from the New Jersey Department of Health linked to administrative databases were used to compare all-cause mortality, repeat revascularization, heart failure readmissions, myocardial infarction, and stroke using Cox proportional hazards and propensity matching with competing risk analysis in 5988 patients with ejection fraction 35% or less who underwent coronary artery bypass grafting (3673, 61.3%) or percutaneous coronary intervention (2315, 38.6%) for multivessel coronary disease between 2007 and 2018. Median follow-up time was 5.2 years (range, 0-13 years); the last follow-up date was December 31, 2020.

Results: After controlling for completeness of revascularization, at 13 years, mortality was 57% (95% CI, 51-63) after percutaneous coronary intervention and 60% (95% CI, 53-66) after coronary artery bypass grafting (hazard ratio [HR], 1.10; 95% CI, 0.93-1.31; P = .28); risk of repeat revascularization was 18% for percutaneous coronary intervention versus 14% for coronary artery bypass grafting (HR, 1.62; 95% CI, 1.17-2.25; P = .003); risk of readmission for heart failure was 16% after percutaneous coronary intervention and coronary artery bypass grafting (HR, 1.13,95% CI, 0.84-1.51, weighted P = .10); risk of myocardial infarction was 10% versus 6%, respectively (HR, 1.91; 95% CI, 1.18-3.09; P = .007); and stroke risk was 3% versus 4%, respectively (HR, 0.79; 95% CI, 0.41-1.53; P = .52). Rate of complete revascularization was lower after percutaneous coronary intervention than after coronary artery bypass grafting and associated with higher mortality after percutaneous coronary intervention (HR, 1.35; 95% CI, 1.20-1.52; P < .001).

Conclusions: Coronary bypass was associated with similar mortality, stroke, and heart failure readmissions, and reduced repeat revascularization compared with percutaneous coronary intervention in patients with ischemic cardiomyopathy if similar rates of complete revascularization were achieved. These findings support consensus recommendations for coronary artery bypass grafting and medical therapy in patients with multivessel coronary disease and left ventricular dysfunction.

Keywords: cardiomyopathy; coronary artery bypass surgery; long-term outcomes; multivessel coronary artery disease; percutaneous coronary revascularization; revascularization; survival.